Link: Frances Sommer Anderson, PhD is a New York-based psychoanalyst and expert on treating chronic pain…
How do you go about treating someone with TMS?
First, I will oversimplify by saying that the treatment is implied in the diagnosis: If hidden/repressed emotions create somatic pain as a distraction or avoidance mechanism to protect the psychological self from intolerable emotional pain, then treatment must aim to identify and help the patient experience and explore those emotions. Now this appears to be very easy for many people–the ones who become pain free after reading a book on TMS. I hear stories about these people from patients and have witnessed this kind of cure among friends and family members. These people didn’t need my help! How they are cured so quickly is a very interesting and important matter that I can’t address further here except to say that I’ve learned a good deal from treating a few of these people over the years after they’ve experienced a recurrence of pain that won’t go away.
The people I treat have usually tried very hard to eliminate the pain and are quite discouraged and critical of themselves because they haven’t been “successful” on their own. They often feel that they’ve “failed” the program, citing statistics in Dr. Sarno’s books about how few people need psychotherapy. As he has described, often TMS sufferers have internalized the value “Americans” place on being independent, self-sufficient, and invulnerable and have been rewarded professionally and financially for these traits. Many of the founders of our country were people in desperate straits who had to work hard to survive. Acknowledging vulnerability and fear could have been more perilous than toughing it out. Thus, it seems to be a part of our national “character.” Another large group of people with TMS have been rewarded for being nice, considerate, peace-makers, for pouring oil on troubled waters, indeed for making sure that there are no troubled waters.
These admirable qualities contribute to building a robust economy and to the smooth working of our social structure. When relied on at the expense of acknowledging one’s own feelings and needs, however, a consequence may be emotional and/or mindbody disorders such as TMS and its equivalents. The disavowal of dependency, vulnerability, and anger/rage contributes to overflowing emotional reservoirs of shame, fear, grief, longing, rage, and even love. The reservoir of rage that Dr. Sarno has brought to our attention, is problematic for many of us in our civilized western culture. Within the last few years, he has increased our awareness of the young child within who needed, and stills needs, unconditional love and acceptance. He has encouraged his patients to get to know that child through journaling and in therapy. In addition, quite a few of my patients have discovered the frustrated, insecure, adolescent who has also been unconsciously disavowed.
So, the treatment begins by exploring the context in which the symptom developed. Often, people do not have an awareness of the emotional impact of the physical/work/family/relationship environment in which they live because they have learned to survive and thrive by disavowing the emotions I described above. I ask for minute details, like a journalist, sometimes annoying with my “picky” questions about “who, what, when, where, and why.” We learn a lot from what they can and cannot answer. My aim is to help them identify “stressors” that can lead to the overflow of an emotional reservoir into a pain symptom. For example, a 36 year-old patient recently told me that, within the past year, his father had died suddenly, he had lost his job, and separated from his life partner. While these life events would cause many of us to have overwhelming feelings, he had scant appreciation of just how stressful these events had been. Thus his therapy began.
While identifying the life events preceding the onset of the pain, I am listening intently to how the person is speaking about the event. How is my patient reacting emotionally to what they are telling me. For example, are they laughing when telling me about what sounds like an enraging/embarrassing/shaming/humiliating situation? Do they seem sad when speaking about sad matters? Can I detect any emotion at all as they speak about a highly volatile interaction or a devastating loss? I often refer to this function of the therapist as the “emotion detector.” In the initial consultation I begin to bring the patient’s attention to this dimension of their participation, carefully probing to assess the extent of their awareness and how they react to my inquiring. We often identify this as an area where they will need to do work both inside and outside of the session.
For people who have great difficulty being aware of what they are feeling about what they are saying, I work intensively on this in each session. I recommend that they take a “feeling inventory” several times during the day and evening: Ask yourself, “What am I feeling about the events that happened during the past hour? How did I feel when my supervisee didn’t meet the deadline and casually brought the work into my office without acknowledging that it was late? How did I feel when our nanny called to say that she had an emergency and had to leave immediately, possibly indefinitely? How did I feel when our 16 year-old son showed up two hours past his curfew, undeniably drunk?” At the beginning of therapy, some people need to take this inventory once every hour.
As we are doing this “emotion detection” work inside and outside the sessions, we are also tracking pain levels as well as presence and absence of pain. This strategy is aimed at making links between emotions and pain symptoms. I offer a few examples to illustrate:
1) A patient had been pain-free all day but noticed that his pain started on the way to the session. I asked what he was thinking and feeling along the way. He realized that he had mixed feelings about being in the session. As we examine these feelings, his pain lessens but is not completely alleviated.
2) A patient is pain-free in the session until she starts to describe an interaction with her husband the previous night. In our discussion, we discover that she was furious with him and afraid of feeling her anger. We spend some time helping her tolerate that feeling right there in the session. As she becomes more comfortable with feeling angry, we talk about some constructive ways to express it to him. Her pain gradually subsides.
3) A patient is in excruciating pain as he enters the session and has no idea what brought on the pain the day before. We begin our search for the emotional triggers and discover that he had been dreading an upcoming phone call to his mother in which he planned to confront her in a way he had never done. As we discussed his strategy and what he was afraid would happen, his pain started to subside.
